Use and Value of the 7-Item Binge Eating Disorder Screener in Clinical Practice

ABSTRACT

Binge-eating disorder (BED) was first recognized as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).1 Two studies2,3 from the 2001-2003 US National Comorbidity Survey Replication reported 12-month and lifetime BED prevalence estimates of 1.2% and 2.6%, respectively, in the United States based on DSM-IV-TR criteria. In a recent study,4 among a representative US adult sample who participated in the National Health and Wellness Survey, 12-month and lifetime BED prevalence estimates based on the DSM-5 were 1.64% and 2.03%, respectively.

Despite the higher prevalence of BED compared with other eating disorders,2,3 a lack of awareness of BED by primary care physicians5 and inadequate physician-patient communication regarding BED6 may result in its underdiagnosis. In a survey5 of physician knowledge about binge-eating and obesity treatment recommendations, 41.6% of respondents reported that they never assessed binge eating. Further highlighting the lack of attention by physicians regarding BED, a study7 documenting patient experiences with BED noted that patients perceived health care professionals as inadequately understanding BED. Another study6 revealed that patients and psychiatrists viewed the core aspects of BED differently; this discrepancy contributed to ineffective communication.

To aid physicians in screening for BED, the patient-reported 7-item Binge Eating Disorder Screener (BEDS-7)8 was developed to examine eating patterns and behaviors in the past 3 months. Candidate screener items were developed based on input from clinical experts on BED so that DSM-5 criteria were accurately represented and tested with patients to ensure ease of comprehension and response.8 On the basis of a comprehensive psychometric evaluation, the BEDS-7 items were selected to maximize sensitivity (100% of respondents receiving a BED diagnosis via clinical interview screened positive), maintain reasonable specificity (38.7% of respondents not receiving a BED diagnosis via clinical interview screened negative), and preserve the content of the DSM-5 criteria.8 Other screening and diagnostic instruments9,10 based on DSM-5 criteria for eating disorders are available. The Eating Disorder Screen for Primary Care9 is a clinician-administered 5-item screener that can be used to identify potential eating disorders in primary care populations or university students for purposes of referral for further evaluation. The Eating Disorder Assessment for DSM-5 (EDA-5)10 is a clinician-administered diagnostic instrument that is intended for use by clinicians to diagnose anorexia nervosa, bulimia nervosa, or BED. In contrast to these other instruments, the BEDS-7 is the only available screening tool that is specific for BED.8 Structured interviews (such as the EDA-5,10 Structured Clinical Interview for DSM-IV,11 and the Eating Disorders Examination12) are the gold standard for diagnosing eating disorders, but these interviews require training for the clinician and time with the patient that is often unavailable.13 The BEDS-7 is a brief patient-reported screening tool that concisely reflects the DSM-5 criteria and as such is less burdensome than structured interviews based on the BED diagnostic guidelines. The objective of this study was to evaluate physician knowledge of and attitudes about BED and to describe the value and ease-of-use of the BEDS-7 in clinical practice.

METHODS

Study Design and Respondents

In this longitudinal study, web-based surveys were administered to primary care physicians serving adults (PCPs-adults) and psychiatrists at 2 time points (wave 1: April 15-May 6, 2015; wave 2: August 19-25, 2015) (Figure 1). The surveys were developed by Shire Development LLC (Lexington, Massachusetts) in collaboration with RTI Health Solutions (Research Triangle Park, North Carolina) and were administered by Nielsen, an online data collection company, utilizing US physician panels. The study was conducted in accordance with ethical principles of the 2008 Declaration of Helsinki and was reviewed and approved by the RTI International Institutional Review Board. Informed consent was obtained before survey participation.

• Primary care physicians serving adults and psychiatrists acknowledge the importance of being knowledgeable about binge-eating disorder (BED).
• Knowledge of and confidence in diagnosing and treating BED were higher in psychiatrists than in primary care physicians serving adults.
• Primary care physicians serving adults and psychiatrists reported that the 7-item Binge Eating Disorder Screener was a valuable and easy-to-use tool.

The wave 1 survey included an introduction to a downloadable version of the BEDS-7 and an invitation to use it in clinical practice. For wave 1, e-mail invitations were sent to a randomly selected subset of physicians from a web panel. Participants were required to be licensed US-based medical doctors; to spend ≥ 50% of their time in direct patient care; to be currently practicing in family or general medicine, primary care, or internal medicine (for PCPs-adults) or in psychiatry (for psychiatrists); and to self-report “no,” “little,” or “some or average” experience with patients with eating disorders. Inclusion criteria were selected for participants to best represent typical practicing PCPs-adults and psychiatrists (ie, not eating disorder specialists). Wave 1 respondents who provided permission to be recontacted were invited to participate in wave 2. Physicians who completed wave 1 received a $35 gift card; those who completed wave 2 received an additional $42 gift card. A prespecified quota of 245 respondents was set for wave 2.

Assessments

Survey assessments (Supplementary Table 1) examined physicians’ knowledge of BED (based on a composite percentage of each respondent’s correct response to the 11 knowledge assessment items; higher scores indicate greater knowledge). Correct responses to the knowledge assessment items were not provided to participants between completing wave 1 and starting wave 2. Survey assessments also examined beliefs and attitudes about the importance of being knowledgeable about BED (based on a composite score from 3 items; higher scores indicate greater acknowledgment of the importance of being knowledgeable about BED), confidence in diagnosing and treating BED (based on a composite score of 3 items; higher scores indicate greater confidence), and the appropriateness of and comfort with drug treatment for BED (based on responses to 2 items; higher scores indicate greater comfort). In wave 1, physicians’ awareness of and perceived value of the BEDS-7 were also assessed. The wave 2 survey addressed BEDS-7 use; the actual value of, ease of, and likelihood of using the BEDS-7 in the future; and reasons for using or not using the BEDS-7.

Data Presentation and Analysis

Analyses focused on respondents completing both waves. For BED knowledge, the mean was taken across each participant’s composite percentage of correct responses. For beliefs and attitudes about the importance of being knowledgeable about BED, confidence in diagnosing and treating BED, and appropriateness of and comfort with drug treatment for BED, composite scores were generated by summing responses to items addressing each of the key concepts. Data are presented using descriptive statistics by physician type (PCPs-adults vs psychiatrists) and BEDS-7 use (users vs nonusers). BEDS-7 users were defined as respondents reporting use of the BEDS-7 in clinical practice during wave 2. Means were compared using paired t tests (wave 1 vs wave 2) or independent t tests (PCPs-adults vs psychiatrists, BEDS-7 users vs BEDS-7 nonusers). Categorical variables were compared using χ2 or Fisher exact tests. Statistical significance was set at P < .05.

RESULTS

Disposition and Characteristics

Approximately 26,000 web survey e-mail invitations were sent to physician panelists, of which 1,047 responded. Among those physicians who responded, 313 did not meet at least 1 of the screening criteria, including 3.15% of respondents who spent < 50% of their time in direct patient care, and 74 withdrew during the screening process. A total of 660 of 973 physicians (67.8%) met all screening criteria.

Among those who qualified for the survey, 90 PCPs-adults were declined, as the target physician-type subquota was met, and 20 physicians (3.0%) withdrew prior to survey completion. A total of 550 respondents (PCPs-adults: n = 278, psychiatrists: n = 272) completed wave 1; 517 respondents (94%) agreed to be recontacted for wave 2. The prespecified target response rate of 47% (245/517) was obtained for wave 2 after 1 week, with 122 PCPs-adults and 123 psychiatrists completing both waves. Most respondents were male, white, and had “some or average” experience with eating disorders (Table 1). Physician groups were similar in terms of their mean time spent providing direct patient care and years of experience; PCPs-adults tended to see more patients per month and to have fewer BED patients and were more likely to work in group practice than psychiatrists (Table 1). At the time of the wave 2 survey, 32.0% of PCPs-adults (n = 39) and 26.8% of psychiatrists (n = 33) reported using the BEDS-7 in clinical practice. BEDS-7 users had been in practice for more years than nonusers (users: PCPs-adults, 20.64 ± 8.1 and psychiatrists, 18.39 ± 10.3; nonusers: PCPs-adults, 18.80 ± 10.5 and psychiatrists: 16.48 ± 10.5).

Knowledge of BED

For BED knowledge, the composite percentage of correct responses increased significantly from wave 1 to wave 2 in PCPs-adults (total: P < .001, nonusers: P < .001) and psychiatrists (total: P < .05, nonusers: P < .01) (Table 2). On average, the composite percentage of correct responses among PCPs-adults was lower than among psychiatrists (both waves: P < .001). Knowledge items for which there were notably lower percentages of PCPs-adults than psychiatrists who responded correctly in both waves were related to diagnostic criteria (not knowing that marked distress must be present and that BED cannot be diagnosed in a patient with bulimia) and to the availability of pharmacotherapy for BED (not knowing that lisdexamfetamine dimesylate is the only US Food and Drug Administration [FDA]-approved treatment for BED). The percentages of psychiatrists who correctly indicated that a BED diagnosis requires that binge-eating episodes occur ≥ 1 time per week for 3 months and that BED cannot be diagnosed in a patient with bulimia were lower than those for all other items.

In wave 2, the percentages of BEDS-7 users (PCPs-adults and psychiatrists) who correctly endorsed statements indicating that there is an FDA-approved treatment for moderate to severe BED in adults and that lisdexamfetamine dimesylate is the only FDA-approved treatment for BED were numerically higher than for BEDS-7 nonusers in both waves. Conversely, the percentages of BEDS-7 users who correctly endorsed statements indicating that a sense of lack of control, in part, defines an episode of binge eating and that BED cannot be diagnosed in a patient with bulimia were numerically lower than BEDS-7 nonusers in both waves.

Beliefs and Attitudes Related to BED

Endorsement of beliefs and attitudes related to the importance of being knowledgeable about BED was high among PCPs-adults and psychiatrists in both waves (Figure 2A and 2B). For PCPs-adults, composite scores related to the importance of being knowledgeable about BED remained steady across waves and were significantly higher for BEDS-7 users than nonusers in wave 2 (P < .05). For psychiatrists, composite scores related to the importance of being knowledgeable about BED significantly decreased from wave 1 to wave 2 overall and in BEDS-7 nonusers (both P < .05).

In both waves, composite scores related to confidence in diagnosing and treating BED were significantly higher among psychiatrists than PCPs-adults (both waves, P < .001). Among PCPs-adults, composite scores regarding confidence in diagnosing and treating BED significantly decreased from wave 1 to wave 2 in the overall group (P < .05) and in BEDS-7 nonusers (P < .01) but not in BEDS-7 users; scores were significantly higher among BEDS-7 users than nonusers (both waves: P < .001, Figure 2C). Among psychiatrists, scores for confidence in diagnosing and treating BED were similar across waves overall but were significantly higher among BEDS-7 users than nonusers during wave 2 (P < .05, Figure 2D).

Composite scores related to appropriateness of and comfort with pharmacotherapy for BED in both waves were generally low, indicating that respondents did not agree that pharmacotherapy was appropriate for BED and that they were not comfortable using pharmacotherapy for BED. However, composite scores tended to be slightly higher among psychiatrists and PCPs-adults (Figure 2E and 2F). Among PCPs-adults, significantly higher percentages of BEDS-7 users than nonusers agreed that it was appropriate to treat BED with pharmacotherapy and that they were comfortable doing so (both waves, P < .01). Among psychiatrists, there were no significant differences in composite scores between wave 1 and wave 2 or between BEDS-7 users and nonusers.

Issues Related to the BEDS-7

Awareness of the BEDS-7. Significantly more BEDS-7 users than nonusers were aware of the BEDS-7 at wave 1 (PCPs-adults: 30.8% vs 6.0%, psychiatrists: 27.3% vs 10.0%, both P < .001, Supplementary Figure 1).

Value, ease, and likelihood of using the BEDS-7. A majority of physicians (> 75%) reported that the BEDS-7 was “very” or “somewhat” valuable (Figure 3A) and was “very” or “reasonably” easy to use (Figure 3B) and that they were “very” or “moderately” likely to use the BEDS-7 in the future (Figure 3C). Among PCPs-adults, the anticipated value of the BEDS-7 was significantly higher in BEDS-7 users than nonusers during wave 1 (P < .001). Among PCPs-adults who were BEDS-7 users, the percentage reporting that the BEDS-7 was “very” easy to use increased significantly from wave 1 to wave 2 (P < .05). Among BEDS-7 users, the likelihood of using the BEDS-7 in the future significantly increased from wave 1 to wave 2 in PCPs-adults and psychiatrists (both P < .05).

Use of the BEDS-7. Most physicians used the BEDS-7 in 1-4 patients (PCPs-adults: 39.5%, psychiatrists: 56.3%) or 5-9 patients (PCPs-adults: 26.3%, psychiatrists: 21.9%); approximately half of these patients screened positive for possible BED. Among physicians who had a patient screen positive for possible BED (PCPs-adults: n = 29, psychiatrists: n = 24), they most often conducted further evaluation (PCPs-adults: 44.8%, psychiatrists: 70.8%) or made a formal BED diagnosis (PCPs-adults: 65.5%, psychiatrists: 54.2%). The most important uses for the BEDS-7 reported by users were assisting in identifying patients with BED and encouraging/initiating discussion on binge eating between physicians and patients (Supplementary Table 2). The most frequently reported reason for not using the BEDS-7 among nonusers was forgetting it was available (Supplementary Table 2).

DISCUSSION

The results of this survey demonstrate that both PCPs-adults and psychiatrists generally acknowledge the importance of being knowledgeable about BED and indicate that the BEDS-7 is a valuable and easy-to-use tool. Knowledge of BED and confidence in diagnosing and treating BED were higher in psychiatrists than PCPs-adults. The most pronounced knowledge gaps for PCPs-adults were related to the exclusionary nature of bulimia for a BED diagnosis, the importance of marked distress for a BED diagnosis (despite the substantial evidence supporting its importance in BED14-18), the existence of an approved pharmacotherapy for BED, and the required symptom/frequency duration for a BED diagnosis. Compared with other facts about BED, psychiatrists were less likely to be aware of the required symptom/frequency duration and the exclusionary nature of bulimia required for a BED diagnosis. The knowledge gap regarding the symptom frequency/duration criteria for BED may, in part, be the result of the change in this criterion from the DSM-IV-TR (at least 2 binge days per week for 6 months19) to the DSM-5 (occurring on average at least 1 binge episode per week for ≥ 3 months1).

The observed knowledge gaps regarding BED in physicians are consistent with previous reports. In one survey,20 one-third of primary care providers who considered themselves familiar with BED did not recognize essential BED diagnostic criteria. In another physician survey,21 26.9% of respondents could not correctly identify a case vignette portraying an individual with BED. Patient surveys also indicate that physicians would benefit from additional BED education, as patients perceive health care professionals as having inadequate understanding of BED7 and as having different views of core aspects of BED.6 Taken together, knowledge gaps in PCPs-adults and psychiatrists related to the DSM-5 BED diagnostic criteria suggest that health care professionals would benefit from educational materials focusing on diagnosing and treating BED. Recognizing that PCPs-adults may be the first health care professionals to detect an eating disorder in an individual,22 increasing their awareness of BED through the BEDS-7 could improve outcomes by facilitating earlier diagnosis and treatment.

Both physician types exhibited significant increases in the composite percentage of correct responses pertaining to BED knowledge from wave 1 to wave 2, with increases observed in PCPs-adults and psychiatrists who were BEDS-7 nonusers. The increased BED knowledge from wave 1 to wave 2 is theorized to be the result of increased exposure to BED between completion of the wave 1 survey and initiation of the wave 2 survey and due to access to the BEDS-7 screener. The lack of a significant increase in knowledge among BEDS-7 users may be partially attributed to their higher overall scores during wave 1 and to preexisting attitudes related to their exposure to eating disorders. Beliefs related to the importance of being knowledgeable about BED were high for PCPs-adults and psychiatrists, but composite scores for psychiatrists significantly decreased from wave 1 to wave 2. This decrease was largely attributable to BEDS-7 nonusers, who exhibited a significant decrease from wave 1 to wave 2; these nonusers also attributed lower value to being knowledgeable about BED during wave 1.

Confidence in diagnosing and treating BED was significantly higher among psychiatrists than PCPs-adults. This increased confidence among psychiatrists may result from a greater BED-related knowledge base among these specialists. Consistent with this hypothesis, another recent study9 found that psychiatrists were more likely than family practitioners to use the DSM-5 as a source of information when diagnosing BED, which could be an indication that psychiatrists have increased awareness of and knowledge concerning BED diagnostic guidelines. Scores related to the appropriateness of and comfort with drug treatment for BED were low in both physician groups and only slightly greater among psychiatrists, despite the fact that psychiatrists exhibited increased knowledge of the availability of an approved pharmacotherapy for BED. This discrepancy suggests that, although psychiatrists are aware of the pharmacotherapeutic option for BED, they may not be comfortable prescribing it. This lack of comfort may be due to several factors, including that the approved pharmacotherapy for adults with moderate to severe BED—lisdexamfetamine dimesylate—is an amphetamine-based agent, which is a controlled substance,23 and that psychosocial therapies have been more widely used as treatment strategies for BED than pharmacotherapies.24,25

The majority of respondents rated the BEDS-7 as valuable (“very” or “somewhat” valuable) and easy to use (“very” or “somewhat” easy). Consistent with the trends observed for value and ease-of-use, a majority of respondents reported that they were likely (“very likely” or “moderately likely”) to use the BEDS-7. Among BEDS-7 users, the most important uses for the BEDS-7 included assisting physicians in identifying patients with possible BED and encouraging and initiating patient-physician discussions. These findings align with the purpose for developing the BEDS-7, which was to develop a screening tool to identify individuals with probable BED so they can then be referred for further evaluation.8 Among BEDS-7 nonusers, the most frequent reason cited for not using the BEDS-7 was forgetting it was available, being focused on other patient issues and health concerns, or lack of time. As the BEDS-7 was designed to help physicians screen patients suspected of possible BED,8 further educating physicians on the existence and ease-of-use of the BEDS-7 could facilitate its use in clinical settings.

Several study limitations should be considered when interpreting these data. First, it cannot be stated that study participants are representative of all practicing PCPs-adults or psychiatrists due to (1) the limited information available in regard to the web panel, (2) the sampling method employed, and (3) the small sample size in relation to the overall number of practicing PCPs-adults and psychiatrists in the United States. Second, sample selection bias may have influenced the wave 2 data, which included only the first 245 respondents who responded. The use of a prespecified quota for wave 2 also does not allow for accurate determination of a wave 2 participation rate because the calculated rate could be a substantial underestimation of the participation rate that would have been observed if all of the wave 1 respondents had been allowed to participate if they elected to do so. Third, this study assessed associations and was not designed to examine or suggest causal relationships. Fourth, although the study sampled respondents from different geographic regions, regional differences were not examined as part of the study. It should also be noted that the BEDS-7 was developed to maximize sensitivity to ensure detection of those with BED; a 100% sensitivity rate and 38.7% specificity rate was obtained in the screeners’ development study.8

CONCLUSIONS

Knowledge of BED and confidence with diagnosing and treating BED were higher among psychiatrists than PCPs-adults, but both physician groups acknowledged the importance of being knowledgeable about BED. These results suggest there is a need for further increases in knowledge of and comfort with diagnosing and treating BED, especially among PCPs-adults. Among PCPs-adults and psychiatrists who used the BEDS-7 in clinical practice, it was considered a highly valued, easy-to-use screener. Results from this study support the utility of the BEDS-7 screener, a brief patient-reported, DSM-5 criteria-based tool for BED, in real-world clinical practice. The BEDS-7 can be valuable in assisting clinicians in identifying BED patients and encouraging/initiating doctor-patient discussions about BED.

Submitted: November 17, 2016; accepted March 16, 2017.

Published online: June 29, 2017.

Potential conflicts of interest: Dr Herman is a former employee of Shire and holds stock and/or stock options in Shire; he is currently an employee of Ironshore Pharmaceuticals and Development, Inc (Wayne, PA). Ms Deal is a former employee of Shire and a current employee of Pfizer and holds stock and/or stock options in Shire and Pfizer. Dr Kando is an employee of Shire and holds stock and/or stock options in Shire. Drs DiBenedetti, Nelson, Fehnel, and Brown are employees of RTI Health Solutions, which received funding from Shire to design and conduct this research.

Funding/support: This research was funded by Shire Development LLC (Lexington, MA). Shire also provided funding to Complete Healthcare Communications, LLC (CHC; Chadds Ford, PA) for support in writing and editing this manuscript.

Role of the sponsor: The study sponsor, Shire Development LLC, was involved in the design and conduct of the study and in the collection, analysis, and interpretation of the data. The final content of this manuscript, the ultimate data interpretation, and the decision to submit it for publication in The Primary Care Companion for CNS Disorders was made by the authors independently.

Previous presentation: These data were presented at the 2016 meeting of the American Psychiatric Association Annual Meeting; May 14-18, 2016; Atlanta, Georgia ▪ Neuroscience Education Institute of Psychopharmacology; November 3-16, 2016; Colorado Springs, Colorado ▪ International Conference on Eating Disorders; June 8-10, 2017; Prague, Czech Republic.

Acknowledgments: Under the direction of the authors, Madhura Mehta, PhD, and Craig Slawecki, PhD (employees of CHC), provided writing assistance for this manuscript. Drs Mehta and Slawecki report no conflicts of interest related to the subject of this article.

Supplementary material: See accompanying pages.

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